PROVINCIAL WHEELCHAIR / BUGGY and WHEELCHAIR CUSHION POLICY (Draft)

PROVINCIAL WHEELCHAIR / BUGGY AND WHEELCHAIR CUSHION POLICY (Draft)

KZN DEPARTMENT OF HEALTH

WHEELCHAIR / BUGGY AND WHEELCHAIR CUSHION POLICY

1.PREAMBLE

The World Health Organization (WHO) describes a wheelchair as “one of the most commonly used assistive devices for enhancing personal mobility”. Provision of wheelchairs to disabled persons is a precondition for enjoying human rights and living in dignity and also assists users to become more productive members of their communities.

Providing wheelchairs that are fit for the purpose not only enhances mobility but also begins a process of opening up a world of education, work and social life. A wheelchair opens doors to learning, employment and social participation to the user.

According to standardization of provision of assistive devices in South Africa, the government has a commitment to improve the quality of life of persons with disabilities.

The national policy on the Free Health Care for disabled people has prescribed that any indigent disabled person is entitled to free assistive device including maintenance /repair of such a device as long as one meets the set criteria

In recent years the KwaZulu-Natal Department of Health has been inundated with increased demand for wheelchairs in all districts. This unprecedented demand has been attributed to factors such as high levels of motor vehicle accidents (MVAs), HIV-AIDS, cross border clients /patients and others. This increased demand for wheelchairs in the province has been compounded by limited resources and poor distribution /issuing of wheelchairs by unqualified persons /organizations

The development of policies and increased training opportunities in the supply, issuing and maintenance of wheelchairs are essential in enhancing service delivery.

The Introduction of this policy as well as effective use /implementation of the policy will assist to improve and strengthen the system of wheelchair distribution and issuing in KwaZulu-Natal

Aim

This policy aims to:

-Provide a framework for the equitable, accessible and appropriate provision of buggies, wheelchairsand wheelchair cushions.

-Enhance mobility, ensure effective postural support and promote functional ability and independence.

-Prevent complications with focus on wheelchair and seating techniques.

-Minimize the tendency of issuing wheelchairs to people without prior assessment by qualified persons /professionals

-Strengthen disability prevention strategy by issuing appropriate size and type of wheelchairs to clients /patients

Elements of thewheelchair and seating services are outlined in the “WHO Guidelines on the Provision ofManual Wheelchair in less resourced settings” (World Health Organization Guidelines onprovision of manual wheelchair in less resourced settings 2008)

1Background

As stated above, a wheelchair is one of the most commonly used assistive devices for enhancing personal mobility, which is a precondition for enjoying human rights and living in dignity and assists people with disabilities to become more productive members of their communities. For many people, an appropriate, well-designed and well-fitted wheelchair can be the first step towards inclusion and participation in society.

A wheelchair / buggy as an assistive device opens doorsfor the user to learning, employment and social participation and integration.
For people with mobility impairments, a wheelchair promotes a normal lifestyle, improves their quality of life and enhances the prospects of employment, education and participation. Simultaneously, it reduces the cost of care and dependency. It also reduces the extent of hospitalization and secondary complications as well as the demand for hospitalization, and therefore liberates scarce resources for other uses.
A wheelchair must meet the user’s individual needs and environmental conditions, provide postural support, be safe and durable
A wheelchair must be available and affordable to the user and it must be maintainable and sustainable in the place of use; taking into account the diversity of users in terms of their personal requirements, environmental and socioeconomic conditions
The unavailability of wheelchairs/ buggies causes a high degree of dependency on the user or even total dependency as well as death.
The unavailability of a wheelchair cushion for a patient leads to serious and sometimes life-threatening complications such as pressure sores

Definition of an appropriate wheelchair

A wheelchair is appropriate when it meets the individual’s needs and environmental conditions; provides proper fit and postural support based on sound biomechanical principles; is safe and durable; is available and can be accessed, maintained andsustained in the country at the most economical and affordable price. (World HealthOrganization Guidelines on provision of manual wheelchair in less resourced settings2008)

Objectives of the policy are the following:

To ensure adequate budgets, appropriate assessment, training and issuing,
To ensure access to wheelchair repairs
To provide guidelines for the issuing of specialized devices by an appropriate health practioner.
To provide clarity of payment, record keeping and maintenance for devices
To ensure all aspects related to the provision of assistive devices will be done in an ethical manner.

Policy Frame work:

1.The Constitution of the RSA, Act 108 of 1996; Chapter 2 Bill of Rights No. 27

2. National Guidelines

2.1 The wheelchair/buggy and cushion policy will be in adherence with the National Health guideline on the Standardisation of Provision of assistive devices in South Africa.

3. World Health Organization

3.1 World Health Organization Guidelines on provision of manual wheelchair in less resourced settings 2008

4. UN Convention on Rights of Persons with Disabilities; Article 20: Parties shall take effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities….

Patient’s rights:

All patients/clients in need of wheelchairs and cushion will receivesuch. (Funds permitting).

Patients will be assessed by a trained rehabilitation worker(supervision by a Physiotherapist /Occupational therapist) and will not be issued with a chair if an assessment has not taken place

Patients that are immobile should not be discharged from hospital until he/she has been issued with a device as it can be seen as a basic human right. Such patients are very vulnerable for serious complications such as pressures sores and death.

In the case that the patient is mobile but it is severely restricted and is about to be discharged, a therapist must take responsibility to ensure that the patient receives a wheelchair, even if it is within 6-8 weeks post-discharge. The situation of patients going home without wheelchairs is not to be encouraged, and departments must make efforts to ensure that this does not happen.

The type of wheelchair/buggy available shall be closely matched to the mobility, functional and positioning needs of a patient. Wheelchairs will not be issued ad hoc without assessment. Official KwaZulu-Natal wheelchair/ buggy and cushion prescription forms should be utilized when assessing the patient (Addendum 1)

All patients shall receive a wheelchair cushion when issued with a wheelchair.Refer to wheelchair cushion criteria (Addendum 2)

Criteria

All wheelchairs, buggies, inserts and cushions are subject to set criteria, guidelines and procedures for issuing. The following criteria should be adhered to :
Adjustability
Suitability
Durability
Sustainability
Addendums as follows:
Motorised wheelchair (Addendum 3.3)
Buggies (Addendum 3.4)

Payment

Payment for mobility devices will be according to the Uniform Patient Fee System and the national Policy of Free Health Care for People with Disabilities.(Addendum3)

Foreign Patients

For billing of foreign patients issued with a wheelchair, please refer to the KwaZulu-Natal Department of Health circular no. 7/5 of 1998: Cross border billing (Addendum 4)
In cases where all avenues were exhausted to obtain financial assistance through the embassies, or to locate next of kin and the patients is occupying a bed, a wheelchair will be issued.

Other sectors:

DOE needs to provide a dedicated budget for wheelchairs/buggies/cushions for children attending mainstream and special schools in accordance with the White Paper 6 – Education for children with special needs.
The existing cross border arrangements between neighbouring provinces should be utilized. Please refer to circular no. 7/5 of 1998: Cross border billing Addendum 4

Budget

The budget should be reviewed on an annual basis and should be based on local needs and address any backlog that may have accumulated.
Budgets must dedicated and ring-fencedfor wheelchairs.
The District Office and Institutionsshall carry the cost of:

All power chairs and the repair thereof
Rigid frame wheelchairs
Manual wheelchairs
Wheelchair cushions
Buggies
Training of clinicians in wheelchair on prescription, measurement and seating.
Spares for wheelchair repairs carried out at designated Wheelchair Repair Centres

Rehabilitation therapists should be involved in the planning, and budgeting for wheelchair services.
Provincial office may assist where the district or an institution’s budget is depleted due to circumstances beyond their control. (NB. This depends on the availability of funds)
Donated wheelchairs will be managed as per recommended procedures (Addendum 5)

Wheelchair Issued at Events / donations.

Donations of wheelchair at events will be in adherence with criteria and guidelines contained in this policy i.e. clients should be assessed & a wheelchair prescribed by a Physiotherapist / Occupational therapist prior to the event.
Preference will be given to suitable clients on the waiting list.
It is the responsibility of the District /institution where the Event is being held to supply the correct wheelchairs required at the Event.
Rehabilitation therapists will only participate in the Events, if Departmental criteria are met.
Donations will only be accepted according to the recommended criteria for wheelchairs issued at the Events (Addendum 6)

Legal & Ethical Issues

The official Lease Contract must be signed by the client /close family member before/ on issuing of any wheelchair or wheelchair cushion, stipulating that the wheelchair and wheelchair cushion will remain the property of the KwaZulu-Natal Department of Health. (Addendum7)
If there is evidence of poor maintenance or abuse, the wheelchairmay be withdrawn from the client (refer to lease contract.)
Clients claiming that their wheelchair and/or cushion was/were stolen must provide an appropriate South African Police Service case number/ affidavit.
Written informed consent to be obtained from the patient/family member/caregiver when issuing a wheelchair.

Training

Patients/clients and caregivers shall be trained by the prescribing health professional on the use & maintenance of wheelchair/ wheelchair cushion or buggy.(Addendum 8)
Newhealth professional graduates/staff should be specifically trained by appropriate trainers in the prescription of wheelchairs, seating as well as the guidelines & policies, after the commencement of employment.

Repairs

Major manual wheelchair repairs shall be done at the KwaZulu-NatalDepartment of Health designated repair and maintenanceworkshops. Minor adjustments can be done at the institution.
Alterations or repairs of wheelchairs and wheelchair cushions should only be done by an appropriately trained wheelchair repairer
All clients will be issued with a wheelchair repair/maintenance booklet for recording of the service history of the wheelchair. Please refer to addendum 8
Repairs under warranty should be dealt with according to business principles. Rehabilitation professionals should ensure that guarantees are utilized within the guarantee period.
The repair of motorised chairs will be done by a suitably qualified technician /accredited service provider /supplier.
Patients in spinal/rehabilitationunits must be trained to do a limited number of wheelchair repairs /maintenance for themselves as part of the rehabilitation.
Maintenance is also the responsibility of the client/ caregiver.

Loan wheelchairs

A limited number of wheelchairs should be available for loan purposes at all health facilities for persons who have temporary mobility impairment or whose wheelchair is waiting to be repaired. It is the responsibility of the institution or district to have a stock of wheelchairs for these purposes.
This loan period applies for a period not exceeding 3 months. This can be renewed for a further period. A loan /lease form needs to be completed for all wheelchair loans. (Addendum 8).

Tender Procedures

National /Provincial tender procedures shall be followed for all wheelchair devices and accessories.
Health professionals directly involved in prescribing wheelchairs and wheelchair cushionswill be nominated to be involved in the tender process.

Responsibilitiesof districts, hospitals & clinics

First issue wheelchairs should be from the hospital or clinic at which the patient was treated.
Replacement chairs and cushions will be provided by the district, hospital and clinics.

Replacement wheelchairs

Replacement wheelchairs are the property of KwaZulu-Natal Department of Health and must be handed in when a new wheelchair is issued. Usable parts from the old wheelchair can be used as recycled spares for repairs to other wheelchairs provided that wheelchair parts are interchangeable.
Ideally a wheelchair should be replaced every 3-5 years (depending on the environment, the type of disability, age of the user and type of wheelchair)
In the case of children, this may need to be replaced every year.
Wheelchairs that are not utilized by the client should also be returned for re-issuing purposes. These chairs must be serviced before re-issuing to another client.

Records

Records should be kept by professionals issuing any wheelchair/buggy. Records of the client’s particulars (Name, Physical address, ID number, Diagnosis, departmental or donated wheelchair).
Specifications of the type of wheelchair/buggy and cushions must be kept.
All the above-mentioned statistics should be submitted monthly on the necessary forms (Addendum9) to the Provincial Office.

Wheelchair assessment

All clients should be assessed /re-assessed and wheelchairs and wheelchair cushions replaced if necessary where the client’s condition deteriorates/changesor due to growth of a child to the extent that replacement is necessary.
Assessments will be performed by clinical professionals who are trained in wheelchair seating services. Students and trainees will work under supervision of a trained rehabilitation practitioner. Different levels of expertise and knowledge can be sought for difficult cases.

Assessments will be done in a clinically acceptable environment, i.e. private, clean and quiet.
Basic equipment required for seating assessments will be available. This will include plinths (bobath), mats, tables, screen, measuring tapes, goniometers, sample devices, markers and infection control supplies.
Assessments will be comprehensively documented on a dedicated seatingassessment form.
Assessments will be based on the ICF framework with a strong focus on posturalsupport, mobility and activity needs, as well as personal and environmentalcontextual factors.
All postural deviations and seating postures will be recorded and filed. Where data iselectronically available, e.g. photographs / pressure mapping both electronic andprinted versions should be filed.
All seating-related risk factors will be investigated (pressure, postural control, criticaljoint ranges, balance and safety).

Prescription of wheelchairs

The institution discharging the client to his her home / point of community integration, e.g. old age home, group home, or the sub-acute and chronic facilities etc. will be responsible for the prescription of the device.
Prescription of wheelchairs/buggies will meet user requirements in terms of postural support, mobility and activity needs, as well as personal and environmental contextual factors.
There shall be no discrimination against clients on the grounds of disability, age, gender, social conditions, financial situation, disease, medical condition or other basis in the assessment or issuing an assistive device.
Prescription will be fully completed on an assessment formwith all patient /client’s details included.
Where possible, a trial in sample products will be conducted during the assessment and prescription phase prior to the final prescription.
If the wheelchair/buggy cannot be supplied immediately, the user will be placed on a waiting list. Thisinformation is to be documented & retained in the department & in the user’s clinical notes, as well as all relevantreferral / discharge letters
The user will be informed of the expected waiting period as well as the process whichwill follow. This information will also be documented in the user’s clinical notes

Seating clinic

Any patient that has a very specific need must be referred to the seating clinic according to procedures. (Addendum10)

Other Relevant Guidelines

Criteria for supply of wheelchairs and buggies (Addendum 11)
Criteria for supply of motorised wheelchair (Addendum 12)
Criteria for care and maintenance of motorised wheelchair (Addendum 13)

Resource implication of policy

1. Human resource implications:

These include:

Training

Training of all rehabilitation practitioners /workers in basic seating.
Training of staff in advanced seating.
Training of all new staff in use of wheelchair & buggy tender/contract.
These workshops should be done on a regular basis & can be provided for both formally & informally.

Implementation

Brief outline of planning process

The policy will be distributed using an official circular route to inform all stake holders of the policy. The policy will be communicated to all stakeholders through the various forums e.g. occupational therapy and physiotherapy forums, and relevant NGO’s

Process of consultation required (if any) and with whom

The draft wheelchair policy will be circulated to all relevant stakeholders including district rehabilitation coordinators, therapy forums, training institutions and NGO’sfor comments/ input /recommendations.

Consultation with rehabilitation therapists prescribing wheelchairs/buggieswill also take place. Thereafter feedback from all stakeholders will be reviewed by the wheelchair policy Task team. This will be done in order to reach agreement on certain issues and to make all stakeholders aware of the existence of the provincial wheelchair policy

Possible Constraints to implementation

Limited or non-prioritization of budget for wheelchairs/buggiesat district and institutional levels

Poor compliance due to high staff turnover particularly therapists

Lack of in-service training for implementers

Monitoring and evaluation

The following indicators are to bemeasured:

Waiting lists
Number of wheelchairs/buggies issued.
Number of wheelchairs repaired
Number of cushions issued.
Number of patients seen at seating clinic.
Client profiles.

References: